Journal of Patient Safety最新文献

{"title":"From Missed Appointments to Missed Opportunities: The Patient Safety Challenge.","authors":"Waseem Jerjes, Azeem Majeed","doi":"10.1097/PTS.0000000000001330","DOIUrl":"10.1097/PTS.0000000000001330","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"256-257"},"PeriodicalIF":1.7,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143524627","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Pharmacovigilance Indicators in Health Services: A Systematic Review. Are There Still Relevant Gaps?","authors":"Alessandra de Freitas Pimentel, Luis P N Lopes, Thaiane de Lima Alexandre, Adrielly de Barcellos Fernandes Ferreira, Albert Figueras, Lusiele Guaraldo, Guacira C de Matos","doi":"10.1097/PTS.0000000000001321","DOIUrl":"10.1097/PTS.0000000000001321","url":null,"abstract":"<p><strong>Objective: </strong>The aim of this study was to identify potentially applicable pharmacovigilance (PV) indicators for health services available in the literature.</p><p><strong>Methods: </strong>We searched MEDLINE, EMBASE, LILACS, IBECS, CUMED, SciELO, and Google Scholar bibliographic between January 1, 2004 and January 23, 2023, and 25 websites from different organizations for studies describing specific PV indicators in health services. The methodological quality of the included studies was assessed using the Appraisal of Indicators through the Research and Evaluation (AIRE) tool. The indicators were differentiated into structure, process and outcome, and also grouped according to the applicability of the PV activities carried out in health services, based on the domains proposed by the Centers for Disease Control and Prevention.</p><p><strong>Results: </strong>We identified 14 studies and 100 PV indicators classified as structural (51%), process (32%), and outcome (17%). The indicators classified according to the aspect of the PV activities they measure cover \"Results of PV/ External impact\" (45%); \"How does the PV unit works/Management of their information\" (32%); \"The PV unit and team\" (23%). According to AIRE, the methodological quality of the included studies varied considerably. In consensus, we selected 55 indicators that could potentially be useful to health services.</p><p><strong>Conclusions: </strong>This systematic review made it possible to identify a considerable number of indicators. Many of them aim to evaluate different aspects of PV activities that can be valuable from a public health and health system perspective. Therefore, we propose a new classification and a set of indicators useful for health services.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"193-202"},"PeriodicalIF":1.7,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143069161","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Saturday Elective Operations: Untapped Opportunity or Dangerous Fool's Errand.","authors":"Joseph D Forrester, Edward Guzman, Rika Ohkuma, J Christopher Knoell, Wendy Prigge, Samuel H Wald","doi":"10.1097/PTS.0000000000001346","DOIUrl":"10.1097/PTS.0000000000001346","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e40"},"PeriodicalIF":1.7,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143781449","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Adaptive Capacity Within the Homecare Setting: The Importance and Value of a Shared Perception of Risk.","authors":"Ingvild Idsøe-Jakobsen, Heidi Dombestein, Rebecca Lawton, Siri Wiig","doi":"10.1097/PTS.0000000000001323","DOIUrl":"10.1097/PTS.0000000000001323","url":null,"abstract":"<p><strong>Objectives: </strong>Patients receiving homecare are living their everyday lives in their own homes. Adapting care to individual needs, preferences, risks, and family situations is seen as essential. The overall aim of this study was to develop empirical knowledge of risk perception in homecare services. The research question that guided the study was: How is a shared perception of risk between health care professionals and leaders a part of providing high-quality care within a homecare setting?</p><p><strong>Methods: </strong>The research design was a multiple-embedded case study including 3 single cases. Participants were recruited from 3 Norwegian municipalities. Two focus group interviews were conducted in each municipality. In total, 19 informants participated, including 11 homecare department leaders and 8 health care professionals. The data were analyzed using thematic analysis according to Braun and Clarke's 6-phase thematic analysis.</p><p><strong>Findings: </strong>Two higher-order themes were developed from the data: \"Risk perception is a collective understanding\" and \"A flawed system requires adapting just to make it work.\" The study showed that, in the homecare departments, leaders' and health care professionals' opinion, flexibility and professional discussions are key to enhancing the system's adaptive capacity. High-quality care is always perceived as person-centered and adaptive. Overgeneralizations and the use of guidelines were perceived as demanding. The findings also showed that making sense of and managing risks within a homecare setting is complex.</p><p><strong>Conclusions: </strong>Bridging the gaps by conceptualizing and acting upon risks in the homecare setting constitutes a fundamental part of adaptive capacity at a system level. However, better alignment of system demands to local risks is needed for sustainable and safe services.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"246-255"},"PeriodicalIF":1.7,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143191097","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Falls in an Australian Hospital During the COVID-19 Pandemic: A Study of Patient Safety Incident Reports.","authors":"Ritin Fernandez, Heidi Green, Olivia Paulik, Kate Christopher, Shona Haigh, Robyn Whitaker, Nqobile Sikhosana","doi":"10.1097/PTS.0000000000001336","DOIUrl":"10.1097/PTS.0000000000001336","url":null,"abstract":"<p><strong>Objective: </strong>Inpatient falls pose a significant challenge in hospitals, impacting patient safety and resources. This retrospective study aimed to analyze the impact of the COVID-19 pandemic on fall incidents in a major metropolitan tertiary referral and teaching hospital in New South Wales (NSW), Australia.</p><p><strong>Methods: </strong>Utilizing clinical informatics, data from Clinical Health Information Exchange (CHIE) database, electronic medical records (eMR), and the NSW Health Incident Information Management System (IIMS)/Incident Management System Plus (IMS+) were collected. Inpatient falls reported at the study hospital between July and December 2019, 2020, and 2021 for patients aged 18 years and above were included. Extracted data encompassed patient demographics, medical history, fall characteristics, contributing factors, and fall incident harm scores. Descriptive and inferential statistics were undertaken using SPSS V 25, and inductive content analysis was used to analyze the narratives relating to the contributing factors for falls.</p><p><strong>Results: </strong>A total of 1399 inpatient falls were reported during the study period. Falls per 1000 occupied bed days (OBD) varied: 3.83 in 2019, 3.41 in 2020, and 4.35 in 2021. A significant increase in fall incidents was observed in 2021 compared to 2020. Most falls occurred on a weekday, particularly between 1400 and 2159 hours. Medicine departments reported the highest number of falls, followed by aged care units. Incident harm scores at level 3, indicating moderate injury, were prevalent across all 3 years. Contributing factors to falls according to the IIMS/IMS+ criteria were diverse, with \"Patient complexity/acuity,\" \"Patient engagement and compliance,\" \"Hazard/unsafe,\" and \"Clinical risk screening/assessment\" emerging prominently. In addition, 7 distinct themes contributing to inpatient falls were identified through inductive analysis.</p><p><strong>Conclusions: </strong>The study highlighted increased inpatient falls (4.35 falls per 1000 OBDs) during the July to December 2021 study period. Understanding fall patterns is vital for improving safety protocols. Emphasising incident reporting, staff training, environmental adjustments, and mobility-related risk management is crucial to reducing inpatient falls and fall-related injury during restricted visitor access during pandemics.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"220-225"},"PeriodicalIF":1.7,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143732652","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Misinformation Risks of Generative AI in Health Care: A Patient-centered Perspective.","authors":"Mohammed Asad, Nawarh Faran","doi":"10.1097/PTS.0000000000001329","DOIUrl":"10.1097/PTS.0000000000001329","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"e21-e23"},"PeriodicalIF":1.7,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143524941","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Mixed Methods SEIPS-based Evaluation of a Patient-centered ED Discharge Process Redesign for Older Adults.","authors":"Pascale Carayon, Kathryn Wust, Hanna J Barton, Manish N Shah, Paula Vw Dail, Barbara J King, Denise M Buckley, Brad Ehlenfeldt, Brian W Patterson, Peter Hoonakker, Nicole E Werner","doi":"10.1097/PTS.0000000000001328","DOIUrl":"10.1097/PTS.0000000000001328","url":null,"abstract":"<p><strong>Objectives: </strong>The transition of older adults from the emergency department (ED) to home remains a potential area of preventable harm. Through a human-centered design process, we developed a patient-centered intervention aimed at improving communication and coordination between ED staff and patients. The intervention included a new electronic health record (EHR)-based template for physicians to enter discharge instructions, a redesigned after-visit-summary (AVS), enhanced nurse training for patient teach-back, and EHR-embedded tips for nurses at the time of follow-up call. Our research objective was to evaluate this patient-centered ED discharge process redesign from multiple perspectives.</p><p><strong>Methods: </strong>Using the SEIPS 3.0 model, we evaluated the intervention, in particular work system barriers and facilitators in the 3 subprocesses of the redesigned ED discharge process: physician writing discharge instructions, nurse/patient communication at discharge, and nurse/patient communication at follow-up call. We used multiple methods to collect quantitative and qualitative data from the perspectives of patients, and ED physicians and nurses.</p><p><strong>Results: </strong>Overall, the redesigned patient-centered discharge process was perceived positively by ED physicians and advanced practice providers, ED nurses, and patients. All 3 groups identified work system facilitators regarding the intervention, in particular the usability of the AVS. Work system barriers pointed to areas for future improvement of the intervention, such as adding prepopulated information to the AVS.</p><p><strong>Conclusions: </strong>Using a human-centered design process, we improved ED discharge for older adults. Our SEIPS-based research and evaluation fit with the learning health system concept as it provides input for future work system and patient safety improvement.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"203-212"},"PeriodicalIF":1.7,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143651445","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Antecedents and Outcomes of Physician Coworker Conflict: A Differential Occupational Model for Health Care Managers.","authors":"Eung Il Kim, Benjamin B Dunford, Wayne Boss, David S Boss","doi":"10.1097/PTS.0000000000001340","DOIUrl":"10.1097/PTS.0000000000001340","url":null,"abstract":"<p><strong>Objectives: </strong>Interpersonal conflict between physicians and their coworkers hinders health care organizations today on an unprecedented scale. Most research on physician conflict has been restricted to 2 occupational groups, nurses and administrators. Yet as health care delivery becomes more complex and interdependent, physician interpersonal conflict impacts all occupational groups. Thus, we seek to provide health care managers with specific guidance about how they might eliminate negative effects of physician-related interpersonal conflict for each occupation.</p><p><strong>Methods: </strong>We examined antecedents and outcomes of physician conflict across 4 occupational groups (office clerical and support staff, professional and technical, nursing, and managerial) in a survey of 1451 US health care employees. Using Multigroup Structural Equations Modeling (MSEM) analysis we estimated each relationship in our model across the 4 occupational groups.</p><p><strong>Results: </strong>We found that workload, perceived HR climate and patient-related incentives predicted physician conflict, and that physician conflict related to burnout, intention to turn over and psychological safety. Most notably, these antecedents and outcomes varied meaningfully across occupational groups.</p><p><strong>Conclusions: </strong>These observed differential effects in our results suggest that managers should carefully consider the needs of different occupational groups separately when designing and implementing interventions to prevent and ameliorate physician conflict. In short, the antecedents and outcomes of physician conflict are different for office/clerical, nurses, professional/technical employees, and management groups and therefore require different solutions. In short, it behooves health care organizations to avoid a one size fits all approach to improving workplace relationships.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":"282-289"},"PeriodicalIF":1.7,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143812756","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Impact of Retained Surgical Items on Patient and Clinical Practice: A Systematic Review.","authors":"Peirong Chen","doi":"10.1097/PTS.0000000000001374","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001374","url":null,"abstract":"<p><p>Retained surgical items (RSIs) are foreign objects left inside after surgery, classified as serious but preventable never events. This review aims to examine the consequences and impact of RSIs, thereby raising awareness and emphasizing prevention. The author reviewed case reports published between 2020 and 2024. A total of 37 cases were evaluated. Excluding 3 asymptomatic patients, 91.89% sought medical help due to discomfort, with 59.46% experiencing pain. On average, 2.33 additional imaging examinations were required. Of the patients, 94.59% underwent a second or more operations, 77.14% of which were open surgeries. Serious complications were observed in 29.73% of cases, and 3 patients died from complications. The average stay to discharge after surgery was 5.94 days. The median incubation time was 1.75 years. RSIs were found across various procedures and anatomic sites, with 67.57% presenting nonspecific symptoms. Only 32.43% of diagnoses were identified through imaging, and 70.27% were confirmed intraoperatively, indicating that the primary diagnosis matched the final diagnosis in only 29.73% of cases. The impact of retained surgical items on patients and health care providers is significant. Prevention is always better than cure.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-05-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144175444","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Evaluating Family Safety Reporting Through an Operational and Research Taxonomy.","authors":"Kate E Humphrey, Patricia A Stoeck, Brynn Elder, Tiffany Ngo, Jennifer Baird, Rachel K D'Anna, Kathryn P Gray, Helen Haskell, Nandini Mallick, Susan Matherson, Sangeeta Mauskar, Dorothy M Miller, Sara Toomey, Christopher P Landrigan, Alisa Khan","doi":"10.1097/PTS.0000000000001368","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001368","url":null,"abstract":"<p><strong>Objective: </strong>Integrating family-reported safety data into hospitals' operational safety reporting systems could enrich them, but requires understanding how reports would be classified. We sought to evaluate how family safety reports would be classified in an operational system and compare classifications with a newer research taxonomy.</p><p><strong>Design/methods: </strong>We prospectively collected safety reports from English and Spanish-speaking families of children hospitalized in a pediatric quaternary hospital's complex care service. Three physicians scored reports using research (modified Bates and colleagues and NCC-MERP) and operational taxonomies. In total, 10% of reports were reviewed independently to determine interrater reliability [kappa (κ)].</p><p><strong>Results: </strong>In total, 132 families provided 289 reports. Research κ (% agreement) was 0.40 (52.0%) for safety classification and 0.58 (68.0%) for NCC-MERP category. Operational κ was 0.46 (62.5%) for severity. κ for preventability, a shared category across operational and research taxonomies, was 0.53 (76.9%). Using operational taxonomy, reports were commonly classified as medications and fluids (29.8%, n=86), severity level 1 (no harm; 34.6%, n=100), with 34.9% (n=101) deemed unclassifiable. Using research taxonomy, reports were most commonly medicine/IV fluids (36.3%, n=105), nonharmful errors (38.4%, n=111), non-safety-related quality (30.8%, n=89), and NCC-MERP C (29.8%, n=86). 63% (n=182) were possibly preventable/preventable.</p><p><strong>Conclusions: </strong>Operational and research taxonomies classify family-reported safety events similarly, though many are nonclassifiable in the operational taxonomy. Research taxonomy characterized family-reported concerns, including quality and environmental hazards, highlighting important aspects that operational systems do not capture. Hospitals and researchers should include family-reported data, and operational systems could add research categories to better capture safety and quality information from families.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-05-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144152555","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}